The compatibility of prescribing guidelines and the doctor-patient partnership: a primary care mixed-methods study

Patients' attitudes

Patients, in the qualitative phase, experienced the implementation of guidelines as rules about treatment, with no flexibility or choice. This involved not being allowed soluble analgesics or prescription quantities, and rules about ‘correct’ cholesterol levels. From a financial perspective, many patients felt entitled to medicines because of their tax and/or prescription charge payments.

Patients were unaware of the concept of patient partnership but, when it was explained, some reacted in a way that suggested it was unrealistic. Some thought it would take too much time, which would, in turn, increase waiting times for appointments; others had experiences of some doctors being unwilling to engage in partnership:

‘What sort of a stupid idea is this? When you need advice they say you must discuss it with your doctor, but [what] if [a] doctor is not willing to discuss with you?’ Patient 17

Although the majority of patients (55%, 156/286) disagreed with the statement ‘My doctor expects me to accept his/her advice without question’, a reasonable proportion (21%, 60/286) believed that was, in fact, the case.

All the patients in the qualitative phase, valued good communication and being listened to but, in general, were less interested in shared decision making. There was evidence of shared decision making with one GP and both of his patients in the study; other patients, however, did not wish to engage, despite some GPs wanting to adopt a shared decision-making approach and, consequently, feeling frustrated. Actively taking part in the consultation but then leaving the actual decision making to the GP was echoed by the quantitative results: although 85% (244/286) of patients preferred to take an active role in consultations, 64% (184/286) wanted their doctor to tell them what to do.

GPs' attitudes

All GPs were aware of prescribing guidelines, but varied in how they viewed and followed them. A minority were very target oriented and showed little interest in patient partnership; the remaining GPs were, in general, supportive of both guidelines and partnership. However, as the latter group of GPs thought that neither concept was fully achievable, they adopted a pragmatic approach. As an example, in discussing concordance, GP8 stated:

‘It's sort of like happiness, it's what we are striving for but you haven't to be too disappointed if you don't always get there.’ (GP8)

Reasons for thinking that partnership was unachievable with some patients included the views that some did not wish to engage, or were hindered by poor education. However, it was also noted that some patients welcomed such involvement:

‘It varies with personality and it's dependent on the ongoing relationship and how much power you give people in the relationship, you know. So, some people, if you give them a copy of a letter that's been sent, some people are overfaced by that, they don't like having that information; some people love it.’ (GP2)

Barriers to patient partnership were identified as lack of time and the habit of being paternalistic. Discussions about patient partnership revealed several aspects that were important for GPs, such as sharing information, sharing the decision, being honest about non-compliance, and being pragmatic. Many of the GPs who were pragmatic voluntarily discussed the tensions they experienced between implementing guidelines and engaging patient partnership:

‘The targets are going to be difficult because patients actually aren't target driven at all and if … they have the feeling that you are driving them in a direction because the end point is the target, then you actually break down the confidential and therapeutic relationship that you have got with them. So, it is really quite difficult to say, “Well, I know you feel fine and I know your blood pressure's almost normal but it's not normal so I am going to add in another horrible toxic drug” … They just feel foul so, I think, for the majority of people, we'll get near but I don't think we will get to target.’ (GP7)

Consequently, many GPs felt they needed to be able to interpret guidelines in the context of individual patients and to reach a compromise by following guidelines and accommodating patient factors, such as patient preferences or the patient's ability to tolerate medicines:

‘There are more and more guidelines coming in and I haven't got a problem with that, I think it's quite useful, as long as they are guidelines and not a rigid stick with which to beat you … because people are different and some people will take tablets and some people won't and some people can tolerate them, some people can't … what is an acceptable risk to one person is not an acceptable risk to another and, as long as you are taking a decision in agreement with the individual, and the guidelines respect that, then I haven't got a problem.’ (GP4)

Prescribing advisers' attitudes

Prescribing advisers interpreted their role as ensuring that guidelines were implemented and associated targets achieved. Although they were familiar with the concept of patient partnership, one of them did not consider it to be relevant to the PCT and the other saw it as an important means of promoting adherence, achieving prescribing targets, and minimising the wastage of financial resources from unused medicines. Partnership was interpreted more as encouraging cooperation with policy than as giving patients a choice.

Areas of tension

By comparing participants' attitudes, several areas of tension were identified.

The number of stakeholders in prescribing decisions

The study identified distinct perspectives, reflecting the diversity of attitudes across the participant groups. Patients and prescribing advisers saw guidelines as inflexible, whereas most GPs valued autonomy and flexibility. In addition, interpretations of patient partnership varied across groups. Participants who placed the highest value on guidelines (prescribing advisers and GPs who were target driven) either dismissed the concept of partnership or interpreted it as promoting cooperation with policy. This suggests an inherent tension between prescribing guidelines and patient partnership.

In the partnership model, consultations are generally seen as a negotiation between the patient and the prescriber. However, guidelines bring a third decision maker — the policy maker — into the equation. What appears to be a negotiation between two parties is, in fact, a negotiation between three; this, then, reduces the chances of all three stakeholders being in agreement and the choices available to patients. In simple terms, for a GP prescribing a drug, this gives rise to the following difficulties that must be overcome:

• Patient refusal — what happens if patients refuse guideline-recommended treatment?

• Patient demand — what happens if patients request treatment that is not guideline recommended?

• Priority — what happens when there is a conflict between patient choice and following guidelines?

Questionnaire responses indicated that most GPs thought patients have a right to refuse treatment, felt pressured when patient requests conflicted with guideline recommendations, and tended to prioritise patient preference over guideline recommendations (Table 3).

Although this study identified several areas of tension between guidelines and patient partnership, half of the patient cases in the qualitative phase showed some elements of successful integration of the two approaches, in that they met guideline requirements and showed basic elements of patient partnership. Analysis of these ‘successful’ cases indicated that they were successful because either the patient trusted the GP and/or the patient took a proactive approach towards their own health.

Summary

Guidelines introduce the policy maker as the third decision maker in a consultation. The policy maker becomes something of a silent member in the room, which affects the partnership or shared decision-making process, thereby creating tension and limiting patient preference. Specific areas of tension between prescribing guidelines and patient partnership, such as patient refusal, patient demand, and conflicting priorities, were identified.

Strengths and limitations

A strength of the study was that the mixed-methods design allowed the multi-actor perspective of the research question to be addressed by eliciting and comparing the perspectives of all three participant groups. One limitation to be aware of is that the sampling strategy used for GPs to recruit patients in the qualitative phase may have created a bias towards recruiting patients who had strong, established relationships with their GP.

However, not all patients considered their current GP to be a ‘good doctor’ and those who did also spoke about other ‘bad’ doctors. A further limitation of the study is that the use of bespoke questionnaires means it is not possible to compare results directly with other studies.

Comparison with existing literature

This study provides evidence on the compatibility of the two approaches in primary care, in an area in which writing has drawn mostly on theory or opinion, rather than empirical data.5–9

The notable exception is a study set in secondary care which found that cardiologists always prioritised evidence-based medicine over patient choice.10 In contrast, this study identified that many GPs prioritised maintaining the doctor–patient relationship over following guidelines.

Implications for practice and research

These findings raise the question of how much autonomy and time doctors realistically have to implement guidelines flexibly in the context of individual patients. The degree of control that guidelines exert in practice has steadily increased as they have evolved from guidance to national standards, then to QOF performance indicators. This trend of increasing enforcement is likely to inhibit shared decision making and patient choice.

Partnership in medicine taking and shared decision making generally refers to patient preference or choice. However, in this study, patient demand was a distinctive theme and one that implies unacceptable patient choice — that is, a choice that is not in accordance with guidelines. This then poses a challenge to both clinicians and policy makers to understand patients' expectations and ensure that reasonable choice is offered. At the other end of the spectrum from patient demand, this study highlighted a tendency for patient partnership to be interpreted as cooperation. Such an interpretation of patient involvement should be avoided and care taken to ensure that shared decision making is promoted as a genuine option for choice, rather than a tokenistic gesture. Further research should explore the components of consultations that lead to the successful integration of prescribing guidelines and patient partnership.

This study was undertaken during the introduction of the QOF into the UK. As primary care embarks on another organisational change, with the advent of GP commissioning, the question of how GPs will adjust to the dual role of doctor and policy maker is raised, as well as the impact this may have on doctor–patient partnerships.